Cholecystocolonic Fistula: Case Report and Literature Review



 

Tatiana Mudrenko, MPAS, PA-C1; Christopher Chiu, MD1

Perm J 2021;25:21.014

https://doi.org/10.7812/TPP/21.014
E-pub: 09/29/2021

Introduction: Cholecystocolonic fistula is a very rare complication of chronic cholecystitis, often diagnosed intraoperatively during interventions for the complications that it could cause. Clinical presentation is nonspecific, and no consensus exists on the management of fistula.

Methods: A case report and literature review of 14 articles published between 2009 and 2020 were included in this study. Most of the articles included were a combination of case report with literature review, and the remainder were solely case reports or literature reviews.

Results: History, physical examination, and radiologic studies have been unsuccessful in the preoperative diagnosis of cholecystocolonic fistula. Treatment choice is balanced on the risks and benefits and is case specific; however, it is always directed toward resolving the urgent complication.

Conclusion: Even though cholecystocolonic fistula is a rare condition, it should be considered in elderly patients with a hx of cholelithiasis and diverticulosis presenting with bowel obstruction. This case report was prepared following the CARE Guidelines.

INTRODUCTION

Cholecystocolonic fistula (CCF) is a very rare complication of chronic cholecystitis. It occurs when the inflamed gallbladder becomes adherent to the adjacent colon developing necrosis and perforation into the lumen of the gut and forming a connection between the gallbladder and the colon. These types of fistulas account only for 8% to 26% of cholecystoenteric fistulas, and it is the second most common after cholecystoduodenal fistulas.1,3–7,9–13

CCFs do not usually cause predictable symptoms and preoperative diagnostic tests often fail to identify the fistula, thus the diagnosis is often achieved intraoperatively. Although many treatment strategies have been attempted, no consensus has been developed to address the optimal management of the CCF. To make providers aware of this uncommon diagnosis and to help with developing optimal management of this rare condition, we present a case of CCF that we encountered at our local hospital in the last 6 months. Furthermore, we conducted a literature review of current articles on the subject and looked at its presenting symptoms and treatment strategies.

CASE PRESENTATION

A 51-year-old Caucasian female presents to her primary care provider with her husband complaining of burning upper abdominal pain, nausea, dizziness, weakness, vomiting, and diarrhea for 2 weeks. The patient appeared dehydrated, was found to be hypotensive, and was sent to the emergency department for further evaluation. In the emergency department, the patient appeared pale and weak, had slurred speech, and was slow to respond. Physical examination was positive for hypotension, hypothermia, and epigastric tenderness without peritonitis. Diagnostic testing showed leukocytosis, hypoglycemia, and metabolic and lactic acidosis. Computed tomography revealed a dilated cecum with pneumatosis, a 4 cm gallstone in the sigmoid colon with surrounding inflammatory changes, sigmoid diverticulosis, and cholelithiasis with pneumobilia (Figures 1 and 2). She received a diagnosis of severe sepsis with acute organ dysfunction with septicemia, cholelithiasis, cholangitis, acute hypoxemic respiratory failure, and encephalopathy. The patient was admitted to the intensive care unit for resuscitation and hemodynamic stability. Later that day she was taken to the operating room for a laparotomy exploratory. She was found to have a CCF, sigmoid colon obstruction secondary to gallstone, and necrosis with perforation of the sigmoid colon. She underwent cholecystectomy, sigmoid colectomy, and right hemicolectomy due to ischemia. The terminal ileum, the proximal transverse colon, and the remaining left colon were left in discontinuity and a wound vac was placed. The patient was transferred back to the intensive care unit and remained intubated. She was taken back to the operating room 4 days later for a washout, small intestine segmental resection, and colostomy placement. She returned to the intensive care unit in critical but stable condition. The patient’s condition slowly deteriorated, and after suffering complications related to her multiorgan failure, she was placed on comfort care.

 figure 1 copy

Figure 1. Axial view in CT showing gallstone in the sigmoid colon.

figure 2 copy

Figure 2. Coronal view in CT showing dilated cecum with pneumatosis.

DISCUSSION

Cholecystoenteric fistula is a rare complication of chronic cholecystitis from cholelithiasis. The chronic inflammation of the gallbladder wall, in conjunction to the pressure from the stones, causes gallbladder wall erosion and fistula formation. This results in decompression of the gallbladder and resolution of gallbladder symptoms. The most common bilioenteric fistula is cholecystoduodenal, accounting for approximately 75% of all fistulas, followed by CCF.1–3,9 However, CCF has a higher morbidity and mortality rate due to the high bacterial load in the colon.1–3,6,7,9–11,13 The connection between the two allows bacteria to enter the biliary system leading to infections and biliary sepsis.7,9 It appears to have an elderly female predominance; however, due to the rarity of the disease, the reason cannot be explained.

CCFs do not usually cause predictable symptoms and preoperative diagnostic tests often fail to identify the fistula; thus, the diagnosis is often achieved intraoperatively. When symptoms of CCF are present, they are nonspecific. Patients most often complain of diarrhea (71%), which is caused by the laxative effect of bile acids being released directly into the colon; in the long run, this can lead to malabsorption, anemia, weight loss, osteomalacia, fractures, dehydration, electrolyte imbalance, and heart failure. Other reported symptoms are jaundice, right upper quadrant abdominal pain, fever, cholangitis, nausea, and vomiting. On rare occasions patients might present with gastrointestinal hemorrhage, septic shock, abdominal abscess, bowel obstruction, and bowel perforation, requiring immediate interventions.1–14 Bowel obstruction most often occurs with a stone that is greater than 2.5 cm and almost exclusively impacting the sigmoid colon, where there is usually pre-existing narrowing of the gut from diverticular disease or other medical conditions.1,2,4–9,11,13,14 Our patient did have a history of diverticulosis and presented to the emergency department with most of the symptoms described above, unfortunately late in the disease process, suffering from a sigmoid colon perforation, obstruction, and ultimately sepsis.

Many imaging techniques have been reported to aid the diagnosis of CCF; however, very few are able reveal the fistula, and the findings are extremely variable. Abdominal plain films often show pneumobilia, bowel obstruction, colonic distention, and the gallstone. Ultrasound may show gallbladder wall thickening, gallstones, and pneumobilia. Barium enema may show a filling defect in the colon, suggestive of obstruction, and if the contrast is able to reach the right colon, on rare occasions reveals the fistulous communication with the gallbladder.7 In certain cases, ERCP reveals the passage of contrast from the gallbladder to the colon, but fails in others.7,10,12 Computed tomography may report bowel obstruction with an abrupt transition point, gallstone impaction, air in the biliary system, gallbladder wall thickening, gallbladder adherent to the colon, the perforation of the sigmoid colon if present, and, rarely, a connection between the gallbladder and the colon. It can also reveal co-existing conditions and bowel viability, thus, making it the gold standard for diagnosis.6,9,11

Although many treatment strategies have been attempted, no consensus has been developed to address the optimal management of the CCF. A wide variety of treatment methods have been described in the current literature; however, it is very patient specific. In otherwise healthy and stable patients, cholecystectomy with closure of the fistula tract with colonic suturing or epiploic patch is a safe approach.3,12,13 However, cholecystectomy in this setting is difficult due to the extensive adhesions in that area.2,3 Thus, others argue for ERCP with stenting or sphincterotomy for these patients. This will decompress the gallbladder and facilitate fistula closure.6–8,10 In the setting of large bowel obstruction, urgent relief of obstruction is crucial, and the intervention is guided by the state of the colon. If the bowel is viable, an enterotomy, endoscopy, or lithotripsy can be considered.1,4–6,8,9,11,13,14 This method does not address the CCF, has a higher recurrence rate, and does not prevent biliary sepsis; however, it may be the optimal treatment for patients that are not fit for surgery due to their clinical status and existing comorbidities. A one-stage approach involving partial/subtotal cholecystectomy, with partial/subtotal colectomy and colostomy has been described; however, it has a higher mortality rate.2,4–8,11,14 A two-stage approach is considered safer; it addresses the immediate complication by performing a diverting colostomy and does not resolve the fistulous defect. The biliary surgery and fistula closure are performed later during the ostomy takedown.5–7,13 Even though no consensus exists on the best management of CCF, treatment should always be aimed at handling the complications of the fistula.

To make providers aware of this uncommon diagnosis and to help with developing optimal management of this rare condition, we presented this case of CCF that we encountered at our local hospital. Although this literature review highlights the uncertainty in clinical presentation and optimal treatment of CCF, given the rarity of this condition, we believe that our case report and literature review findings have a strong contribution to the existing literature.

Table 1. Timeline of relevant past medical history and interventions

Date Summaries from initial and follow-up visits

Diagnostic testing

(including dates)

Interventions
09/18/19 + FIT test   Colonoscopy ordered
12/13/19 Gastroenterology Colonoscopy shows diverticulosis  
02/18/2020 Pt was seen by primary for abd pain, N/V/D and dizziness Low BP Patient sent to ED with her husband
02/18/2020 ED: acute sepsis with acute organ dysfunction with septicemia, hypovolemic shock, severe metabolic acidosis, AKI, hypoglycemia, 4 cm gallstone in sigmoid colon and dilated cecum. CHEM 7, CBC, CBC, blood cultures, LFT, lactic acid, troponin, influenza, ABG, UA, RBC antibody, MRSA, venous blood gas, ABO-RH typing, XR chest, CT abd and pelvis Patient intubated, central line started, Foley, NPO, NGT, bicarb gtt, 1L LR, levo gtt, surgery consult
02/18/20 Consult with general surgery Not a candidate for endoscopic decompression/stone extraction NGT, IV abx, ICU for resuscitation
02/18/20 General surgery reassess   Surgical case requested
02/18/20 Patient taken to OR   Exploratory laparotomy, cholecystectomy, colectomy sigmoid, hemicolectomy right, wound vac
02/22/20 Patient taken back to OR for washout   Small intestine segmental resection and colostomy and a wound vac over the subcutaneous tissue in the midline
02/24/20 Neurology consulted for patient being poorly responsive

EEG: diffuse slowing

CT head: negative

Continue supportive care for metabolic encephalopathy
03/10/20 Patient decompensated with desaturation   DNR/DNI
03/15/20 Patient passed    
       
       
Relevant past medical history and interventions
  Chronic GERD    
  Diverticulosis dx by colonoscopy    

Included are relevant personal, family, and psychosocial history including important past interventions, outcomes, and follow-up.

CONCLUSION

CCF is an extremely rare complication of chronic cholecystitis in elderly comorbid females. It is often diagnosed intraoperatively during interventions for the complications that it could cause. The condition has nonspecific symptom presentation, although some symptoms can be related to the gallbladder or colon, has nonspecific radiologic findings and a wide variation in treatment approaches, thus carrying a high morbidity and mortality rate. Treatment choice is balanced on the risks and benefits and is case specific; however, it is always directed toward resolving the urgent complication, such as obstruction or sepsis.

Even though CCF is a rare condition, it should be considered in elderly patients with a hx of cholelithiasis and diverticulosis presenting with bowel obstruction. According to our research, early diagnosis and immediate appropriate intervention is crucial. Further research is needed to aid in defining the best diagnosis and treatment strategy for patients with CCF.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Funding Statement

No funding was provided for this work.

Acknowledgments

We thank Rahnea Sunseri, MD (Medical Director and Assistant Professor at University of the Pacific Physician Assistant Program), Mark P. Christiansen, PhD, PA-C (Associate Clinical Professor and Program Director and Chair of the University of the Pacific Physician Assistant Program), and Dr Kristine A. Himmerick, PhD, PA-C, DFAAPA (Director of Assessment and Accreditation at University of the Pacific, School of Health Sciences).

Author Affiliations

1Department of General Surgery, The Permanente Medical Group, Inc.

Corresponding Author

Tatiana Mudrenko, MPAS, PA-C (Tatianamudrenko@yahoo.com)

Author Contributions

Tatiana Mudrenko, MPAS, PA-C, participated in the literature review and drafting and submission of the manuscript. Christopher Chiu, MD, participated in the study design and drafting of the final manuscript. Both authors have given final approval to the manuscript.

Abbreviations:

CCF= cholecystocolonic fistula

Informed Consent

Consent was not obtained from the patient due to the nature of the paper.

References

1. Hajjar R, Létourneau A, Henri M, et al. Cholecystocolonic fistula with a giant colonic gallstone: The mainstay of treatment in an acute setting. J Surg Case Rep 2018 Oct;2018(10):rjy278. DOI: https://doi.org/10.1093/jscr/rjy278

2. Sinha S, Pullan RD. Cholecystocolonic fistula: An unusual cause of large bowel obstruction. Br J Hosp Med (Lond). 2006 Aug;67(8):434–5. DOI: https://doi.org/10.12968/hmed.2006.67.8.21980

3. Chick JFB, Chauhan NR, Paulson VA, Adduci AJ. Cholecystocolonic fistula mimicking acute cholecystitis diagnosed unequivocally by computed tomography. Emerg Radiol 2013 Dec;20(6):569–72. DOI: https://doi.org/10.1007/s10140-013-1132-x

4. Reddy AK, Dennett ER. Cholecystocolonic fistula: a rare intraluminal cause of large bowel obstruction. BMJ Case Rep 2016 Aug;2016:bcr2016217141. DOI: https://doi.org/10.1136/bcr-2016-217141

5. Michael N, Ranney D, Vekstein A, Montgomery S. Cholecystocolonic fistula in the setting of sigmoid perforation from gallstone. Am Surg 2019 Dec;85(12):e608–10. DOI: https://doi.org/10.1177/000313481908501214

6. Gonzalez-Urquijo M, Rodarte-Shade M, Lozano-Balderas G, Gil-Galindo G. Cholecystoenteric fistula with and without gallstone ileus: A case series. Hepatobiliary Pancreat Dis Int 2020 Feb;19(1):36–40. DOI: https://doi.org/10.1016/j.hbpd.2019.12.004

7. Costi R, Randone B, Violi V, et al. Cholecystocolonic fistula: Facts and myths. A review of the 231 published cases. J Hepatobiliary Pancreat Surg 2009;16(1):8–18. DOI: https://doi.org/10.1007/s00534-008-0014-1

8. Aiolfi A, Ceriani C, Sozzi M, Siboni S, Bonavina L. Cholecystocolonic fistula and gallstone obstruction. Eur Surg 2017 Sep;49(6):254–60. DOI: https://doi.org/10.1007/s10353-017-0489-6

9. Carlsson T, Gandhi S. Gallstone ileus of the sigmoid colon: An extremely rare cause of large bowel obstruction detected by multiplanar CT. BMJ Case Rep 2015 Dec;2015:bcr2015209654. DOI: https://doi.org/10.1136/bcr-2015-209654

10. Gibreel W, Greiten LL, Alsayed A, Schiller HJ. Management dilemma of cholecysto-colonic fistula: Case report. Int J Surg Case Rep 2018;42:233–6. DOI: https://doi.org/10.1016/j.ijscr.2017.12.017

11. O’Brien JW, Webb LA, Evans L, Speakman C, Shaikh I. Gallstone ileus caused by cholecystocolonic fistula and gallstone impaction in the sigmoid colon: Review of the literature and novel surgical treatment with trephine loop colostomy. Case Rep Gastroenterol 2017 Mar;11(1):95–102. DOI: https://doi.org/10.1159/000456656

12. Aguilar-Frasco J, Rodríguez-Quintero JH, Moctezuma-Velázquez P, Ruben-Castillo C. Unexpected cause of severe ascending cholangitis in a patient with chronic calculous cholecystitis. BMJ Case Rep 2018 Aug;2018:bcr2018226402. DOI: https://doi.org/10.1136/bcr-2018-226402

13. Toh JW, Balasuriya H, Stewart P. An unusual cause of large-bowel obstruction: Cholecystocolonic fistula and gallstone ileus. Clin Gastroenterol Hepatol 2016 Sep;14(9):e107–8. DOI: https://doi.org/10.1016/j.cgh.2016.03.028

14. Cheong J, Gilmore A, Keshava A. Gastrointestinal: Cholecystocolonic fistula: A rare cause of large bowel obstruction. J Gastroenterol Hepatol 2016 May;31(5):909. DOI: https://doi.org/10.1111/jgh.13279

15. Riley DS, Barber MS, Kienle GS, et al. CARE guidelines for case reports: Explanation and elaboration document. J Clin Epidemiol 2017 Sep;89:218–35. DOI: https://doi.org/10.1016/jclinepi.2017.04.026

Keywords: case report, cholecystitis, cholecystocolonic, cholecystoenteric, fistula

ETOC

Click here to join the eTOC list or text ETOC to 22828. You will receive an email notice with the Table of Contents of The Permanente Journal.

CIRCULATION

2 million page views of TPJ articles in PubMed from a broad international readership.

Indexing

Indexed in MEDLINE, PubMed Central, EMBASE, EBSCO Academic Search Complete, and CrossRef.


                                             

 

 

ISSN 1552-5775 Copyright © 2021 thepermanentejournal.org

All Rights Reserved